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DIMITRY AVERIN AND MAXIM BELOGRAD

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Modern restorative techniques are driven by ultimate esthetics demand while maintaining maximum
amount of intact hard tissues.?

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Occlusal Veneers, Rationale for ultraconservative posterior restorations

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FOUNDERS

Walter Devoto
Dr. Walter Devoto Born in
Chiavari on 29/03/1965
graduated in Dentistry in 1991
at Genova University.

Initially in the anterior segment - minimally invasive bonded feldspathic and glass-ceramic veneers
have become the treatment of choice with proven long-term success 1,2. However, fracture of
ultraconservative ceramic restorations may cause a concern when considering the same treatment
modality for posterior region especially with restorations covering the entire occlusal surface - so
called occlusal veneers.

Angelo Putignano
M.D. degree and D.D.S. post
graduate certificate from
University of Ancona-Italy.

FOUNDERS ENDO
To minimize the risk of ceramic fractures and withstand occlusal loads, the standard guidelines for
lithium disilicate occlusal veneers 3 recommended by the manufacturer (Ivoclar Vivadent) advocate
at least 1,0-1,5 mm of occlusal clearance and chamfer preparation of 1mm. However, such requirement
may be in conflict with current minimally invasive concepts.

Pio Bertani
Pio Bertani is a full member of
the prestigious association...

Fabio Gorni
Fabio Gorni is an active
member of the Italian Society
of Endodontics and the Italian
Academy...

First and foremost, adhering to above mentioned recommendations may result in excessive removal
of dental structure ranging between 40-50% 4. Considering that the tooth may be already
destroyed by caries, attrition or erosion - maximum tooth preservation is of paramount importance.
Previous studies revealed that excessive preparation will cause noticeable decline of the remaining
tooth structure strength 5. Moreover, available long-term clinical data on ceramic partial coverage
restorations have demonstrated that ceramic may fracture even despite recommended thicknesses
of at least 1.5 mm.6,7 It means that the more the prep - the more the longevity of tooth-restoration
complex is jeopardized. As a result, traditional restorative protocols aiming to reinforce the toothrestoration complex at the expense of removing remaining tooth structure are self-contradictory and
may lead to catastrophic failures.7 Finally, traditional thickness demands are mostly based upon the
results of laboratory tests with limited clinical evidence.8

MEMBERS
Monaldo Saracinelli
Ive been a student of prof.
Fabio Toffenetti and
Riccardo Garberoglio.

Jordi Manauta
Was born in Mexico City,
where he graduated cum
laude. in dentistry from
UNITEC.

Gaetano Paolone
My passion is aesthetic
direct and indirect
adhesive dentistry in
anterior and posterior
teeth.

Daniele Rondoni
Born in Savona in 1961
where he lives and has

Consequently, limited clinical application of such aggressive preparation guidelines made the dental
community seek for more ultraconservative alternatives. It should be emphasized that even Ivoclar
Vivadent company is supporting researches in the area of ultra thin restoration.9 Notwithstanding we
have sparse long-term clinical evidence in this field at the moment, the review will attempt to
present state-of -the-art concepts regarding ultra-thin restorations - both for ceramic and composite.
?In the first part, the rationale for ultraconservative concept will be discussed, and protocol for teeth
with preserved occlusal enamel will be elaborated. While the second part will investigate indications
for ultra-thin technique when occlusal enamel is lost accentuating dentin as the main substrate for
bonding. In that context distinct contraindications and limitations will receive special attention.

worked in his own

laboratory since...

Vincenzo Musella
Vincenzo Musella
graduated in dental
technician. Proud friend
and student of...

Giuseppe Marchetti
Giuseppe Marchetti was
born in Parma (Italy) in
October of 1972 and
graduated from...

Simone Grandini
Chair of Endodontics and
Restorative Dentistry,
University of Siena, Italy.

Giovanna Orsini
Giovanna Orsini is a well
known researcher in Italy
and internationally.

Paulo Monteiro
My passion for esthetic
dentistry began when I
attended the last year...

BIOMIMETIC CONCEPT
In the restoration of teeth it is important to avoid primitivistic approaches
concentrating solely on characteristics of restorative materials - such as strength, hardness etc. The
key to successful and simple (not primitive!) restorative technique is to use the intact tooth as a guide
to biomechanical and esthetic reconstruction and utilize those principles through hard tissue
bonding. The backbone of tooth strength is its internal stress distribution mechanism. It is provided
via dentino-enamel junction (DEJ), which constitutes a superb lesson from nature on how to achieve
strong, durable bonding between significantly dissimilar materials: the hard, brittle outer layer of
enamel and the softer, but tougher dentine. In primitive biomimetic model, DEJ is often compared to
adhesive layer in terms of stress absorption. However, it is not completely correct. Adhesive layer
poorly imitates DEJ. The reason is that biomechanically DEJ should be seen as a graded band or
interPHASE rather than a discrete interFACIAL line. Namely gradual change in mechanical properties
is the most important feature of the DEJ 10. Such graded transition from enamel to dentine may
sustain higher loads than a direct bond between two distinct adhesive layers and thus it stands in
stark contrast to the adhesive interFACES between artificial dental restorative materials and dentine.

Louis Hardan
Head of Restorative and
Esthetic department in
Saint-Joseph University
in...

Patrizia Lucchi
Patrizia Lucchi Graduated
in Dentistry cum Laude in
1995 at the University of
Verona

Anna Salat
Dr Anna Salat graduated
with a degree in dentistry
from the International
University of Catalonia

Giulio Pavolucci
After graduation magna
cum laude in Dentistry, I
started focusing my daily
work on...

Marcos Vargas
Dr. Marcos Vargas
attended Cayetano
Heredia University School
of Dentistry in Lima...

THE CORE CONCEPT - PRESERVE ENAMEL AND MINIMIZE FRACTURES This fact leads us to the
first lesson - in order to avoid fractures of ultra-thin restorations -manipulations should be confined to
the framework of enamel. It is well documented that not only adhesion but also fracture resistance of
ceramic restorations bonded with resin to enamel was higher than those bonded to dentin. 11-14 And
vice versa - when supported by enamel the fracture load of lithium disilicate onlay becomes less
sensitive to its thickness, especially in the thickness range from 0,6 mm.15

Stefan Koubi
Dr. Kuobi graduated from
University of Marseille
where he...

Engin Taviloglu
Dr. Taviloglu graduated
from ?stanbul University
School of Dentistry in...

Dimitar Filtchev
Co-founder of the Laser
Dental Center and the
Implant...

Angie Segatto
My commitment to arts has
determined my
specialisation.

Kilian Molina
Kilian is required as a
regular lecturer in indirect
restorative...

The second evident lesson - in terms of modulus of elasticity covering of enamel with a similar
material is essential. The latter is best represented by lithium disilicate. Otherwise, elastic modulus
mismatch between restorative material and the cement/tooth supporting structure may generate
unfavorable stress distribution and stimulate crack initiation.
Additionally, it highlights the
importance of achieving ultra thin layer of adhesive cement, whose low modulus of elasticity may
change beneficial stress distribution between enamel and glass-ceramic. It is especially actual for thin
ceramic restorations, where fractures were shown to initiate from the cementation surface. 16 On the
flip side, minimized thickness of cement layer (20 microns) makes it less sensitive to its low modulus
of elasticity. Adhesion is the prerequisite as only through bonding will the material behave as the
genuine part of the tooth, which is not actual for zirconia as an example.

Gregory Camaleonte
I was born in 1980 in
Marseille-France and i have
graduated in 2006 from...

Caroline Werkhoven
Caroline Werkhoven
graduated in 2002 at
ACTA, the dental faculty in
Amsterdam..

Ajay Juneja
Ajay Juneja finished his
BDS in the year 1995...

To sum up - confining your preparation primarily to enamel allows to significantly reduce restoration
thickness. Considering that in recent researches reduced ceramic thicknesses of 1.0 and 0.5 mm did
not impair the fracture resistance of pressable lithium-disilicate ceramic onlay restorations 9, reduced

Carlos Fernndez
Villares
Member of SEPES Spanish
Soc...

ceramic thickness and ultraconservative preparation may be considered as an option for standard
guidelines. This means that in early and medium occlusal wear in a patient with low and medium load
requirements prep thickness of 0,5 mm instead of 1 mm can be used. The only prerequisites are both
prep in enamel and sound adhesive cementation.

Sulivan Leite
Sulivan Leite graduated
from the Ribeirao...

Maciej Zarow
Author of book edited by
Quintessence: EndoProsthodontics: guidelines
for clinical practice ...

Dan Lazar
Dan Lazar, graduated from
the Faculty of Dentistry in
2005 in Cluj-Napoca...

Murad Akhundov
Dr. Murad Akhundov
graduated from the
Faculty of Dentistry in
Baku...

However, for veneerlays reduced ceramic thicknesses should be recommended with caution due to
increased risk of fracture at regions of geometrical changes (the border between vestibular and
occlusal components).9,17

MEMBERS ENDO
Simone Grandini
Chair of Endodontics and
Restorative Dentistry,
University of Siena, Italy.

Louis Hardan
Head of Restorative and
Esthetic department in
Saint-Joseph University
in...

Filippo Cardinali
Graduate in Dentistry and
Dental Prostheses at the
University of Ancona in
1992. Active Member of...

On the other hand, if restoration is adhesively fixed to enamel - possible fracture would most
probably be limited to the ceramic restoration without involvement of the underlying tooth substrate,
while catastrophic failures involving dentin and root may occur with standard thickness restorations.
In terms of management of this failures, the former can be easily corrected by renewing the
restoration 4; in contrast the latter may entail endodontic treatment or even induce subgingival tooth
fracture. This highlights the advantage of minimally invasive strategies, preserving the structural
integrity of teeth.

Riccardo Tonini
He is active member of the
Italian Academy of
microscopic Dentistry and
Active member of...

Paolo Generali
Doctor Generali was
graduated from Pavia
University in the year...

CLINICAL CHALLENGES. ABFRACTION AND DENTINAL EXPOSURE Frequently clinician face situations
where cervical enamel is missing or lacking. In order to overcome this challenge the combination of
direct and indirect approaches is an option. Direct composite filling will allow to place ceramic margin
1-2 mm supragingivally and stay in enamel while maintaining predictable stress distribution patterns
between enamel and ceramic.

CLINICAL CHALLENGES. ABFRACTION AND DENTINAL EXPOSURE

CLINICAL CHALLENGES. ABFRACTION AND DENTINAL EXPOSURE

CLINICAL CHALLENGES. ABFRACTION AND DENTINAL EXPOSURE

CLINICAL CHALLENGES. ABFRACTION AND DENTINAL EXPOSURE

CLINICAL CHALLENGES. ABFRACTION AND DENTINAL EXPOSURE

CLINICAL CHALLENGES. ABFRACTION AND DENTINAL EXPOSURE

CLINICAL CHALLENGES. ABFRACTION AND DENTINAL EXPOSURE

CLINICAL CHALLENGES. ABFRACTION AND DENTINAL EXPOSURE

CLINICAL CHALLENGES. ABFRACTION AND DENTINAL EXPOSURE

One should never prepare teeth - prep of veneers always starts from the preparation of mock-up.?

Bur selection is based on the necessity of achieving ultrathin tissue reduction ( here - 0,3 mm) and
chamfer margin.

Appropriate consequence of burs, stones and polishers provide a finished preparation that is smooth
and has no sharp ?internal-line-angles which would result in areas of high stress ?concentration.

The preparation margin should allow an optimum adaptation of the final restoration so that creation
of a delicate chamfer is recommended.

Enamel should be etched for 30 seconds and rinsed with water. Tooth surfaces then have to be
conditioned with adhesive (here - Heliobond Ivoclar Vivadent) according to the manufacturers
instructions. For e.max restorations it is better to adhesively cement them with a dual- polymerizing
composite resin (Variolink II; Ivoclar Vivadent) or heated composite. Any excess composite resin must
be removed and margins covered with an air-inhibiting glycerine gel for photocuring.

The intaglio surfaces of the restorations are etched with 4.9 % hydrofluoric acid (IPS ceramic etching
gel; Ivoclar Vivadent) for 20 seconds. Next etched surfaces are thoroughly rinsed with water and air
dried. Having that done, additional cleaning with Ivoclean may be performed to be sure that ceramic
surface is free of any organic contents (phospholipids present in saliva) which may decrease bond
strength. Subsequently a silane coupling agent is applied.

The cleaning step can also be done with orthophosphoric acid.

Final aspect of the restorations

New smile of the patient

The key to the long-term stability of ceramic structures is the ability to effectively utilize the
properties of restorative materials and supporting structures.
In this section the special attention was given to enamel while in the next part the philosophy of
ultratrathin tabletops on dentin will be discussed. ?
References
1. Hahn P, Gustav M, Hellwig E (2000). An in vitro assessment of the strength of porcelain veneers
dependent on tooth preparation. J Oral Rehabil 27:1024-1029.
2. Troedson M, Derand T (1998). Shear stresses in the adhesive layer under porcelain veneers. A finite
element method study. Acta Odontol Scand 56:257-262.
3. Beier US, Kapferer I, Burtscher D, Dumfahrt H. Clinical performance of porcelain laminate veneers
for up to 20 years. The International Journal of Prosthodontics. 2012; 25:7985.
4. .Edelhoff D, Sorensen J. Tooth structure removal associated with various preparation design for
posterior teeth. Int J Periodontics Dent 2002;22:2149.
5. St-Georges AJ, Sturdevant JR, Swift EJ Jr. Thompson JY. Fracture resistance of prepared teeth
restored with bonded inlay restorations. J Prosthet Dent. 2003; 89:5517.
6. Naeselius K, Arnelund CF, Molin MK. Clinical evaluation of all-ceramic onlays: a 4-year retrospective
study. Int J Prosthodont. 2008; 21:404.
7. Murgueitio R, Bernal G. Three-Year Clinical Follow-Up of Posterior Teeth Restored with LeuciteReinforced IPS Empress Onlays and Partial Veneer Crowns. J Prosthodont. 2012; 21:3405.
8. Ahlers MO, Morig G, Blunck U, Hajto J, Probster L, Frankenberger R. Guidelines for the preparation
of CAD/CAM ceramic inlays and partial crowns. Int J Comput Dent. 2009; 12:30925.
9. Guess PC, Schultheis S, Zhang Y, Strub JR. Influence of preparation design and ceramic thicknesses
on fracture resistance and failure modes of premolar partial coverage restorations. The Journal of
Prosthetic Dentistry.
10. 1.White, S. N. et al. The dentino-enamel junction is a broad transitional zone uniting dissimilar
bioceramic composites. J. Am. Ceram. Soc. 83, 238240 (2000). ?11. Clausen JO, Abou Tara M, Kern M.
Dynamic fatigue and fracture resistance of non-retentive all- ceramic full-coverage molar
restorations. Influence of ceramic material and preparation design. Dental Materials. 2010; 26:5338.
12. Piemjai M, Arksornnukit M. Compressive fracture resistance of porcelain laminates bonded to
enamel or dentin with four adhesive systems. Journal of Prosthodontics. 2007; 16:45764.
13. Layton D, Walton T. An up to 16-year prospective study of 304 porcelain veneers. Int J Prosthodont.
2007;20(4):389-396.?14.Peumans M, De Munck J, Fieuws S, et al. A prospective ten-year clinical trial of
porcelain veneers. J Adhes Dent. 2004;6(1):65-76.
15. Li Ma, Petra C. Guess, and Yu Zhang Load-bearing properties of minimal-invasive monolithic
lithium disilicate and zirconia occlusal onlays: finite element and theoretical analyses. Dent Mater. 2013
July ; 29(7): 742751.
16. Zhang Y, Kim JW, Bhowmick S, Thompson VP, Rekow ED. Competition of fracture mechanisms in
monolithic dental ceramics: flat model systems. J Biomed Mater Res B Appl Biomater. 2009; 88:40211.
17. Quinn JB, Quinn GD. A practical and systematic review of Weibull statistics for reporting strengths
of dental materials. Dent Mater. 2010; 26:13547.

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